The Centers for Medicare and Medicaid Services (CMS) did not implement fines with the first round of reporting, but that could change this round, noted Lâle White, Executive Chairman and CEO of XIFIN Inc., a healthcare IT company. White offered perspectives on PAMA’s impact to medical labs during EWC earlier this week.

“In this second period of data collection, it’s becoming
even more important for us to collect data accurately, precisely, and provide
nearly perfect information on this because we can see the impact is fairly
significant to our industry, and with payers ratcheting down their pricing,
it’s becoming even more significant,” White said.

The daylong workshop dedicated to PAMA compliance featured
legal and informatics
experts, consultants, and also laboratory healthcare executives who shared
lessons learned from the previous reporting cycle.

Sarah Simonson, Director of Client Management at Change Healthcare, advised labs to test their data extraction process now; produce a small sample of full data; then collaborate to filter out the exclusions, such as Medicaid and self-pay, among others. Simonson also recommends that labs designate a project champion.

Diana Voorhees (above), Principal/CEO for DV and Associates Inc., notes that “One benefit of the PAMA price reporting process is it can help labs identify coding errors that may not have been detected.” Voorhees was a presenter at the PAMA private payer price reporting workshop. (Photo copyright: DARK Daily.)

Things Clinical Labs
Should Watch for During the Validation Process

Looking forward, July 1, 2019, marks the start of the data
validation period. Here are some things labs should focus on and look out for.

Payments that are not applicable: These would include test codes paid under Medicare’s Physician Fee Schedule; denied ($0.00) payments; unresolved appeals; capitated payments; and payments where the associated test volume cannot be determined.

For example, when a private payer denies payment for a laboratory test, payments of $0.00 or “zero dollars” are not considered a private payer rate for purposes of determining applicable information under the new Clinical Laboratory Fee Schedule (CLFS), according to CMS. Laboratories should not report “zero dollars” for a laboratory test code where a private payer has denied payment within a data collection period.

Very low payments: Data reporters may be tempted to exclude very low payments. However, Joyce Gresko, JD, a Partner in the firm Alston and Bird LLP, based in Washington, DC, cautions that this choice may trigger civil monetary penalties. PAMA gives CMS the authority to issue civil monetary penalties if labs fail to report data, or if they misrepresent or omit reported data, according to CMS’ website.

Look outside the data
collection window: While CMS specifies that labs report payments received
between Jan. 1, 2019, and June 30, 2019, there may be important and related
test data points prior to and after those dates, says Craig Young, Senior
Financial Analyst for XIFIN. The adjudication date is key to helping report
correctly, he said.

When in doubt, leave
it out: Young emphasized double checking that payers have stated the unit correctly
to help ensure the correct volume will be reported per test, per price. And he
adds, when in doubt, leave it out, but be prepared to defend yourself if you do.

PAMA is particular in that it regularly resets the rates that Medicare pays for clinical diagnostic laboratory tests under the CLFS based on the data that labs submit. For the initial implementation of PAMA price reporting, CMS did not independently verify the accuracy of labs’ self-determination, but CMS Administrator Seema Verma recently made some provocative statements concerning analyzing claims data.

The CMS is “working to automatically detect claims that have
inappropriately unbundled the panel tests,” Verma wrote in a
letter to Senate Finance Chair Chuck Grassley (R-Iowa). As Modern Healthcare reported, “[CMS]
is scrutinizing lab test bills submitted to Medicare to make sure the
government hasn’t been overpaying laboratories because of inappropriate coding.”

Mining private payer price datasets out of billing systems
can be tedious, difficult, and the data may be overwhelming, said Trish Hankila, Vice President
of Finance for South Bend Medical Foundation
in South Bend, Ind., one of the EWC PAMA presenters. Hankila advises running a
global report to determine the scope of the project. Ultimately, diligence is
required, and labs will benefit from developing their PAMA team as soon as
possible.